Dentistry Now
6702 Dalrock Rd. #100
Rowlett, TX 75089
Patient Name: _____________________________
Medical Information
Are you under a physician’s care now?
Yes No
If yes, please explain: _______________________________________________
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Are you on a special diet?
Do you smoke or chew tobacco?
Do you use controlled substances?
Do you have osteoporosis or other bone condition?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No If yes, please explain: ______________________________
No If yes, please explain: ______________________________
No If yes, please explain: ______________________________
No If yes, please explain: ______________________________
No If yes, please state how much: _______________________
No
No
For Women: Are you:
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
Yes No
Yes No
Yes No
Are you ALLERGIC to any of the following? (Please Circle)
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other Allergies & Explanations: _______________________________________________________________________________
Do you have, or have a recent history of, any of the following? (Please Circle)
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
High Cholesterol
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Hypoglycemia
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Rheumatism
Do any of these require antibiotic premedication prior to dental treatment? Yes No
Have you ever taken any of the bisphosphonates, such as Bonivia, Aredia, Fosamax, Bondronat, Actonel, Aclasta, or Zometa? Yes No
Please expand on the items you circled above if needed. Also, is there any disease, condition or problem not listed above that you
think we should know about, or is there any activity your doctor says you cannot do? If so, explain: ____________________________
_____________________________________________________________________________________________________________
Dental Health & Appearance
What is the primary concern you would like us to address first? ________________________________________________________
_____________________________________________________________________________________________________________
Approximate date of last dental visit: _____________________________________________
Have you ever had any serious problem associated with previous dental treatment? Yes
No
If so, explain:
___________________________________________________________________________________________________
What, if anything, has happened in previous experiences at the dentist that was reason not to return?
_____________________________________________________________________________________________________________
Do you have any of the following? (Please Circle)
Tenderness while chewing
Head, neck or face pain
Food catches between teeth
Pain when biting
Sensitivity to sweets
Clicking or popping of jaw
Tender or bleeding gums
Sensitivity to hot or cold
Clench or grind teeth
Missing teeth
Swellings or sores in mouth
Snore regularly
If you have missing teeth, have you had them replaced? ________________
If you have had missing teeth replaced, are you happy with the results? ___________________________________________________
Do you feel (or have you ever been told) that you don’t have fresh breath? ________________________________________________
How often do you brush your teeth? ___________ How do you prefer to clean in between your teeth? (floss, waterpik, etc)
_________________________________________ How often? ____________
Cosmetic Evaluation
Are you happy with your smile? __________________________________________________________________________________
Please rate your smile from 1 to 10 (1= I hate my smile, 10= awesome) ____________
If you could, what, if anything, would you change about your smile? _____________________________________________________
__________________________________________________________________________________________________________
If you would like an improved smile please check off all that apply:
Lighten all front teeth showing
Lighten single tooth
Close spaces between teeth
Rebuild fracture(s)
Lengthen
Shorten
Straighten rotation
Straighten angulations
Eliminate crowding
Eliminate dark or stained filling
Reduce gum showing in smile
Repair uneven edges
We respect your right to choose the level of care that fits your needs. Please check all that apply to you:
 I desire to keep my own teeth for life, if possible. I want my teeth to look good, feel good, and last for a long time.
 Spreading payments out over time may help me to achieve the excellent results I desire.
 Phasing treatment, by priority, over a few years may make it feasible for me to achieve the results I desire.
 I am interested in a plan for long-term dental health. However, I am currently unable to pursue this, and would appreciate
help with emergencies and hygiene maintenance for now.
 Although I am not interested in a plan for long-term dental health, I do desire an office that will treat teeth in need of
immediate/emergency attention, as well as keep me up to date on hygiene maintenance care.
Please add anything you feel is important: _______________________________________________________________________
Authorization and Consent
1.
2.
3.
4.
To the best of my knowledge, all of the preceding answers are true, complete, and correct. I hereby authorize Dr. Karns
to take necessary radiographs (x-rays), study models, photographs, and any other diagnostic aids deemed appropriate to
make a thorough diagnosis of the patient’s dental needs. I also authorize him to perform treatment, therapy or
medication deemed necessary by the doctor and agreed upon by the patient. I understand that the use of anesthetic
agents or nitrous oxide gas embodies a certain risk.
I also understand that responsibility for payment for dental services provided for myself and my dependents is mine and
is due and payable at the time services are rendered. There may be additional charges for late payments, broken
appointments, returned checks and collection costs.
I understand that it is necessary to give 24 hours prior notice to change or cancel any dental appointment in order to
avoid the $50 broken appointment charge.
INSURANCE: I understand that any insurance estimates given to me by Dentistry Now are estimates and cannot be a
guarantee of payment by my insurance company. As a courtesy, Dentistry Now will assist you in processing your dental
insurance claims. I understand that I am responsible for the entire balance. I give Dentistry Now permission to give my
insurance company any information that is necessary to process my insurance claim.
I would like my insurance company to pay: Me
Dentistry Now
Patient or Responsible Party: _____________________________________________ Date _____________________
I am the
Patient
Parent/Guardian of Patient
Doctor Reviewed: _____________________________________________________ Date _____________________